Thursday, January 31, 2019

Algorithmic Unfairness Without Any Bias Baked In
"Discussion of (un)fairness in machine learning hit mainstream political discourse this week, when Representative Alexandria Ocasio-Cortez discussed the possibility of algorithmic bias, and was clumsily "called out" by Ryan Saavedra on twitter.
...
"Bias in the data is certainly a problem, especially when labels are gathered by human beings. But its far from being the only problem. In this post, I want to walk through a very simple example in which the algorithm designer is being entirely reasonable, there are no human beings injecting bias into the labels, and yet the resulting outcome is "unfair".

Wednesday, January 30, 2019

Axel Ockenfels points out that the Frankfurter Allgemeine Sonntagszeitung has a recent piece on "Tauschen wir die Nieren?" ("Do we exchange kidneys?"). I can't find it online, but here's a picture:

Google translate renders the opening paragraphs as follows:

"Patients wait a long time for donor organs. That can be changed - with a proposal that has received the Nobel Prize.
Organ donation is literally a matter of life and death. Anyone who receives the urgently needed organ in good time lives on. In Germany, however, many are waiting for the necessary transplantation - often for years. At the same time, the number of organ donations is falling. So how can the number of donated organs be increased so that affected people can live? That's a tricky question, because too many answers tend to limit the voluntary nature of the donation. On Wednesday, the topic is on the agenda of German politics, when the Health Committee of the Bundestag deals with the amendment of the Transplantation Act.
The economists Dorothea Kübler and Axel Ockenfels advise the politicians to take a look at living donations. Kidneys or parts of the liver can also be donated by living people - and this is much less common in Germany than in other countries. The proposal goes in the direction of the FDP parliamentary group around the chairman Christian Lindner, who are pushing for more living donations. In a motion for the health committee on Wednesday, the FDP is proposing to allow the cross-donation of two couples and an anonymous live donation to an organ pool. "

"Would knowing the exact odds make any difference in the parents’s choices? If they’d been warned about their slim chances, would they be more likely to swap in a backup? If they still went ahead with a big gamble, should the lottery administrators take that as a signal of how deeply they care about their picks?

"The school district has tapped three academics to study those very questions in an effort to make the lottery process more transparent, simple and equitable this year.

"At its Monday night meeting on Meadow Street, the Board of Education’s Finance & Operations Committee recommended approving a non-financial agreement with three assistant professors — Princeton’s Adam Kapor and Christopher Neilson and University of Chicago’s Seth Zimmerman — to recommend how the district could do a better job marketing and communicating about a revamped enrollment process.

"As part of the agreement, New Haven will change the algorithm that it uses to assign students in 2019-20. Modeled on applications in New York, Chicago and Boston, the new model will ideally reward students for listing the schools that they’d like to attend rather than for gaming the system."

The project started with a study of the system's current, immediate acceptance algorithm

"In the paper, which waspublished in the American Economic Review in 2016, Kapor, Neilson and Zimmerman said that there’s currently more uninformed parents making mistakes than sophisticated gamblers making savvy bets. They concluded that “offering some means to learn about admissions probabilities for different portfolios” would likely be “welfare-improving.”"Figuring out exactly what that will look like is the subject of Kapor, Neilson and Zimmerman’s next experiment.

As part of the memorandum of understanding that the Finance & Operations Committee reviewed on Monday, the academics agreed to provide a data analyst who will assist the Choice & Enrollment Office in-house at no charge for the next two years. With additional surveys and data analysis, they’ll review how the revamped lottery changes placement outcomes, family satisfaction and student achievement."

Sunday, January 27, 2019

There seems to be good evidence that kidneys for transplantation are bought and sold in some parts of the world. However I'm not aware of any good data on how much of this trade involves people from wealthy countries, as opposed to internal commerce in less well resourced countries.

It turns out that the "hundreds" in the National Health Service data are 400, over a period of 16 years, which averages out to 25 Britons a year.

"Around three million Britons have chronic kidney disease, with the biggest causes uncontrolled diabetes and high blood pressure. It contributes to 45,000 early deaths every year.NHS figures show almost 400 UK residents have received follow-up support after a transplant abroad over the past 16 years. But medics say the true number is likely to be higher because most are advised by brokers not to tell the NHS what they have done."

I don't know what kinds of health data the NHS collect, but in principle it would be easy to track all patients who return to the UK with a transplant from overseas, because such patients immediately need to get prescriptions for daily immunosuppressive drugs. (However I don't think we track these data in a centralized way in the U.S.)

HT Frank McCormick
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Here some of what I've gleaned in the past:

Monday, December 17, 2018

Australia's parliament has published a report on organ trafficking in Australia. They didn't find much trafficking there, but recommend that data be more vigorously collected. They report that only one case of (attempted) paid organ donation has come to the attention of the authorities, but that it was successfully prevented, and the intended recipient died. The report ends with a case study of an anatomical exhibit using human cadavers.

"We conclude that the scientiﬁc literature does not reﬂect a large number of patients buying organs. Organ purchases were more often assumed than determined. A reporting code for transplant professionals to report organ trafﬁcking networks is a potential strategy to collect and quantify cases."

"Dec 14, 2018, was a dark day for universal health coverage (UHC). To begin with, a federal judge in Texas, USA, ruled that the Affordable Care Act (ACA) is unconstitutional.1 That same day, the new President of Mexico, Andrés Manuel López Obrador, announced his intention to abolish the country's largest public insurance programme, known as Seguro Popular (People's Health Insurance).2 The ACA and Seguro Popular have extended health coverage to millions of previously uninsured families, most of them among the poorest in their respective countries. Signed into law in 2010, the ACA roughly halved the number of uninsured, from 46·5 million then to 26·7 million in 2016, towards the end of the Obama administration.3, 4 Following legislative approval, Seguro Popular began full-scale implementation in Mexico in 2004. Public expenditure increased to finance coverage for non-salaried workers and their families, approximately half of Mexico's total population, who were excluded from employment-based social insurance. By 2018, 53 million beneficiaries had access to 290 essential and 65 high-cost interventions.
...
"The challenge to the ACA has been headed by the right wing of the US Republican Party, whereas the attack to Seguro Popular comes mostly from the far left factions of the President's Morena party. This is an example of the way in which opposing political extremes can converge in their attack against centrist positions.
...
"Seguro Popular is one of the most thoroughly evaluated programmes in the world. A 2006 Lancet Series set out the evidence base for the design of this innovative initiative.7, 8 A comprehensive review9 published 8 years into implementation identified a large body of peer-reviewed articles, including one of the few randomised assessments of a large-scale social intervention.10 The evidence strongly points to major benefits of Seguro Popular in terms of financial protection and effective coverage,11 without labour market distortion.12 In a recent cover article on UHC, The Economist featured Seguro Popular among the most successful efforts in low-income and middle-income countries, noting how “studies suggest that Seguro Popular has drastically reduced the number of Mexicans facing catastrophic health costs and reduced infant mortality”

"Dr. Martin Wijkstrom had two jobs to perform Wednesday evening: Drive a donor kidney from Pittsburgh to Erie, Pa., then implant the organ in a patient at UPMC Hamot.
...
“I had already picked up the kidney at a Pittsburgh hospital and had just charged my Tesla in Cranberry Township,” said Wijkstrom, a UPMC transplant surgeon. “I was driving to get back on (Interstate 79) to go to Erie when I struck a pothole.”

"The pothole caused one of Wijkstrom’s tires to go flat. He was stuck in the Cranberry Mall parking lot with a donor kidney, 108 miles from the hospital where a patient waited to receive it.

"His Tesla didn’t carry a spare tire. Though the kidney was secured in a refrigerated container in Wijkstrom’s trunk, the surgeon had about 12 hours to implant the organ for the best chances of success.

“It wasn’t an emergency situation but we needed to put the kidney into the patient as soon as possible,” said Wijkstrom, who said he had transported kidneys in his car three or four previous times.
...
"Brad Dostlik was driving his Nissan Sentra near the mall, listening to his portable police scanner.
He heard a dispatcher send police to the surgeon’s car and notify them about the kidney. Dostlik, who was headed to the nearby Field & Stream store, decided to see if he could help.
...
“He asked if I could take him to Erie,” Dostlik said. “I had a full tank of gas, so why not?”
...
“I learned a lot of stuff during the trip,” Dostlik said. “I don’t think I could do what he does.”
...
"The two men shook hands and the surgeon walked into the hospital with the donor organ, just 40 minutes later than expected.

“The surgery was uneventful,” Wijkstrom said. “The patient is doing well, his kidney is making some urine already.”

"BRUSSELS — A Belgian ban on the Muslim and Jewish ways of ritually slaughtering animals went into effect on New Year’s Day, part of a clash across Europe over the balance between animal welfare and religious freedom.

"With both animal rights advocates and right-wing nationalists pushing to ban ritual slaughter, religious minorities in Belgium and other countries fear that they are the targets of bigotry under the guise of animal protection.
...
"Laws across Europe and European Union regulations require that animals be rendered insensible to pain before slaughter, to make the process more humane. For larger animals, stunning before slaughter usually means using a “captive bolt” device that fires a metal rod into the brain; for poultry it usually means an electric shock.
...
"But slaughter by Muslim halal and Jewish kosher rules requires that an animal be in perfect health — which religious authorities say rules out stunning it first — and be killed with a single cut to the neck that severs critical blood vessels. The animal loses consciousness in seconds, and advocates say it may cause less suffering than other methods, not more.

"Most countries and the European Union allow religious exceptions to the stunning requirement, though in some places — like the Netherlands, where a new law took effect last year, and Germany — the exceptions are very narrow. Belgium is joining Sweden, Norway, Iceland, Denmark and Slovenia among the nations that do not provide for any exceptions.
...
"The idea for the ban was first proposed by Ben Weyts, a right-wing Flemish nationalist and the minister in the Flanders government who is responsible for animal welfare. Mr. Weyts was heavily criticized in 2014 for attending the 90th birthday of Bob Maes, who had collaborated with the Nazi occupation of Belgium in World War II and later became a far-right politician."

"Formally known as bail-bond recovery agents, bounty hunters frequently carry firearms and have the right to forcibly enter homes and apprehend people who jump bail.

"Yet getting a license is relatively easy, and hardly anyone is turned away — even if they have a history of violence, a Seattle Times investigation has found.
...
"The lax requirements for bounty hunters are at odds with the weapons and tactics the agents are allowed to use. To get a license, an applicant must take 32 hours of training, which can include self-study, and must pass a 50-question, multiple-choice exam. The state has no formalized curriculum or certification process for instructors. Only the person teaching the firearms portion of the training is required to be certified through the state.

"By comparison, to get a license to perform manicures and style hair, a cosmetologist must receive 1,600 hours of training from a state-approved and licensed instructor."
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Tuesday, January 22, 2019

"Nearly 680,000 Americans have irreversible kidney failure, or end-stage renal disease (ESRD), and need dialysis or a kidney transplant. More than 475,000 ESRD patients receive dialysis at least three times per week to replace kidney function. Nearly 100,000 Americans are on the waitlist for a kidney transplant right now. Depending on where a patient lives, the average wait time for a kidney transplant can be upwards of three to seven years.

The National Kidney Foundation is calling on Congress and the Administration to make organ transplantation a top priority and has identified several critical areas to be addressed from a legislative and regulatory standpoint. These priorities will create a strategic and effective path forward towards increasing the number of kidney transplants and decreasing the number of patients who die waiting.

1. Living Donation

a. Expand financial assistance offered to living organ donors to cover all expenses related to organ donation including lost wages; travel expenses including transportation, lodging and food; child care or dependent care expenses incurred during the donor’s recovery; living donor medical care and follow-up care for donation; paperwork or legal costs related to the donation; and other expenses related to the donation.

Monday, January 21, 2019

"Test strips are a multi-billion-dollar industry. A 2012 study found that among insulin-dependent patients who monitor their blood sugar, strips accounted for nearly one-quarter of pharmacy costs. Today, four manufacturers account for half of global sales.

"In a retail pharmacy, name-brand strips command high prices. But like most goods and services in American health care, that number doesn’t reflect what most people pay.

"The sticker price is the result of behind-the-scenes negotiations between the strips’ manufacturer and insurers. Manufacturers set a high list price and then negotiate to become an insurer’s preferred supplier by offering a hefty rebate.
...
"For a patient testing their blood many times a day, paying for strips out-of-pocket could add up to thousands of dollars a year. Small wonder, then, that a gray market thrives. The middlemen buy extras from people who obtained strips through insurance, at little cost to themselves, and then resell to the less fortunate.

"That was the opportunity that caught Chad Langley’s eye. He and his twin brother launched the website Teststripz.com to solicit test strips from the public for resale. Today they buy strips from roughly 8,000 people; their third-floor office in Reading, Mass., receives around 100 deliveries a day.

"The amount the Langleys pay depends on the brand, expiration date and condition, but the profit margins are reliably high. For example, the brothers will pay $35 plus shipping for a 100-count box of the popular brand Freestyle Lite in mint condition.

"The Langleys sell the box for $60. CVS, by contrast, retails the strips for $164.
...
"While some resellers use websites like Amazon or eBay to market strips directly to consumers, the biggest profits are in returning them to retail pharmacies, which sell them as new and bill the customer’s insurance the full price.
...
“Test strips are basically printed, like in a printing press,” said David Kliff, who publishes a newsletter on diabetes. “It’s not brain surgery.”

"The Swiss-based International Social Security Association estimates that every year, surrogate mothers give birth to around 20,000 children worldwide. Agencies and parents estimate that between 800 and 1,000 go on to live with Spanish parents, but there are no official figures. There are numbers, however, for international adoptions undertaken by Spaniards, and these have fallen from 5,541 in 2004 to 799 in 2015.

"Yet if the estimates are correct, international surrogacy has overtaken international adoption in popularity. Instead of the international adoption process, which can take up to eight years, it seems that those wanting to be parents are more frequently opting for the quicker route, and paying between €45,000 and € 60,000 in the Ukraine or Russia or up to €120,000 in California – one of 14 American states where the practice is legal.

"Every country has different legislation. Ukraine, for example, only allows heterosexual couples to use surrogates. In Canada, the United Kingdom and Portugal, surrogacy is only allowed in the altruistic sense, meaning the surrogate mother receives no direct economic benefit. And the latter two countries only let nationals use surrogacy. India, a former worldwide power in surrogacy, has vetoed it for foreign couples, and is on the verge of making it illegal for economic profit. Mexico too, particularly the State of Tabasco, has recently restricted surrogacy laws.
...
"“The best solution to avoid abuses is to legislate it. It’s like organ transplants – regulating the legal practice gets rid of organ trafficking,” says Pedro Fuentes, president of a pro-surrogacy parental association that brings together around 400 families, Son Nuestros Hijos. Fuentes is a gynecologist and alongside his husband, he is also the father of a six-year-old boy who was born in California to a surrogate mother. He gets emotional when he tells the story of how he met the surrogate mother and the warm relationship they developed. He said that her own ethics also guided the process, as she had decided to use her body as a surrogate to help a gay couple.

"The association itself has a code of ethics and recommends not trusting “agencies that don’t let you meet the mother, which guarantee results, and which offer package deals saying you won’t have to worry about anything.” Also, they suggest that parents work with a woman who has already given birth. The association certainly makes the case for altruism but it is also open to economic compensation.
...
"The association asks: “When is a women being exploited? When you pay her or when you don’t?”
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"The majority of the judges, however, contend that the “best interests” criterion is not the sole factor to be taken into account. Judges should also ponder the State’s interest in preventing the commodification of children and motherhood. But more strikingly, the Supreme Court argues that it is not obvious that it goes in the best interests of the twins to be legally declared as the sons of Ramón and César and not of the surrogate mother. It is striking, in my view, to argue along those lines when the surrogate mother is a woman who has relinquished her motherhood and the intending parents are not only willing to be the parents, but, most importantly, are the “social” fathers."

Saturday, January 19, 2019

Yesterday was Match Day for urologists, a medical specialty that runs its own residency match, in advance of the NRMP.

They write: "This year's Match once again proved urology is a competitive specialty for aspiring young physicians. More than 430 applicants registered for the 2019 SAU/AUA Urology Residency Match. Of those who registered, 90 percent submitted preference lists, competing for a record 339 available positions across the country. When the matching algorithm was processed, 85 percent matched to a vacancy within 136 registered and accredited U.S. training programs, leaving only nine vacancies unmatched."

There are 137 non-military accredited urology residency programs in the United States. (Military programs cannot participate due to government regulations regarding eligibility.) For 2019, 135 non-military accredited urology residency programs in the United States listed 339 positions with 330 vacancies being matched. 389 applicants submitted preference lists netting 59 unmatched applicants. Of the senior medical students in the U.S. applying, 91% percent were matched.

Friday, January 18, 2019

There was a time when death came in threes: neurological, respiratory, and circulatory processes all shut down more or less together, because when a body lost one of these the others inevitably followed very quickly. But what makes most deceased organ transplantation possible is that respiration and circulation can be maintained on a ventilator after the end of neurological activity, so that organs can remain oxygenated after the brain has died.

The Uniform Determination of Death Act (UDDA) states that an individual who has sustained either:
"an irreversible cessation of circulatory and respiratory functions, oran irreversible cessation of all functions of the entire brain, including the brain stem, is dead."

A recent Hastings Center Report discusses brain death on the 50th anniversary of its 'birth'.

Abstract: This special report is published in commemoration of the fiftieth anniversary of the “Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death,” a landmark document that proposed a new way to define death, with implications that advanced the field of organ transplantation. This remarkable success notwithstanding, the concept has raised lasting questions about what it means to be dead. Is death defined in terms of the biological failure of the organism to maintain integrated functioning? Can death be declared on the basis of severe neurological injury even when biological functions remain intact? Is death essentially a social construct that can be defined in different ways, based on human judgment? These issues, and more, are discussed and debated in this report by leading experts in the field, many of whom have been engaged with this topic for decades.
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“Capron, one of the architects of the UDDA, summarized the situation well in 2001 when he described efforts to determine when death has occurred as both ‘well settled, yet still unresolved.’
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The article suggests that we won't have to worry about precise definitions of death once we don't need deceased donors for transplantation any more, but I'm not so sure. Ventilators help keep people alive while their bodies are struggling, and some will recover. But if not, there is still often a decision to be made about when to disconnect the ventilator, and make it available for someone who still has a chance of recovery.

"Last year, 955 people left organs for other critically ill patients after their death, as the German Foundation for Organ Transplantation (DSO) announced. That was an increase of nearly 20 percent compared to 2017 with 797 donors and the first major increase since 2010.
...
"a discussion on new organ donation rules has started in parliament across parliamentary boundaries. So far, withdrawals are only allowed with expressly agreed consent, but many postpone the occupation with this topic again and again.

"Spahn is therefore campaigning for a "double contradiction solution" ["doppelte Widerspruchslösung"]. Accordingly, everyone is automatically considered a donor. One should be able to say no to this, otherwise - as a double barrier - relatives would have to be asked. In an open debate in the Bundestag at the end of November broad reservations against such a new regulation became clear.

"Instead, a group led by Greens leader Annalena Baerbock and left-leaning boss Katja Kipping suggests a mandatory recurring query, such as collecting new passports or identity cards - with the option of not yet deciding."
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Tuesday, January 15, 2019

"When the gunman in the Las Vegas mass shooting died, he left behind a hoard of guns and firearm accessories in his two Nevada homes and the hotel suite he used as a perch for his attack.
...
"Now, the main lawyer involved in passing on Mr. Paddock’s nearly $1.4 million estate to the families of the 58 people he slaughtered at an outdoor country music festival is facing a quandary. Should the firearms be sold to raise as much money as possible for the bereaved, or would it be more appropriate to destroy the guns in an emblematic rejection of the kind of violence that Mr. Paddock carried out?
...
"Mr. Paddock died without a will. Lawyers for the victims encouraged Mr. Paddock’s mother — who, under Nevada law, became the heir by default — to give his assets to the estates of the 58 people killed by her son. The mother, Irene Hudson, transferred her right to inherit the estate in March of last year.

"In addition to those killed, hundreds of others were injured in the shooting. However, lawyers say the compensation should go to the loved ones of the dead rather than the injured, saying the money would have greater impact on their lives than if the large number of people hurt in the rampage were also beneficiaries.

"When the governmentlaunchedCanada’s official recreational-pot market on Oct. 17, it was banking on the idea that many users would prefer to buy legally and that the black market would quickly begin to fade. It says things seem on track, with “early reports of a 65 percent reduction for illegally sourced products,” according to a spokeswoman for the minister in charge of the cannabis file.

But there are also signs things aren’t going as expected.

In a national poll Ipsos conducted for Global News a month after legalization, more than a third of Canadian cannabis users said they were still buying from their regular dealers and hadn’t even tried the legal system.

...

"The government’s most jolting decision, illegal dealers here said, was to structure the new industry in a way that tended to bar them from it. In 2015, when the government first committed to legalization, many of them planned to apply to open private shops.

“All of us thought, ‘Okay . . . I’m going to be able to come out of the shadows and I’m going to be able to pay taxes,’ ” David said. “As time went on, it became clear that’s not what they were after.”

"In Quebec and several other Canadian provinces, all cannabis stores are government-run, leaving no path to legality for people like David, who has worked in the underground industry for more than a decade, operating his business full time for several years."

"Early applications have been expanding for years, but last month some big-name schools reported record-setting spikes. Totals were up 9 percent at Dartmouth College, 19 percent at Duke University, 21 percent at Brown University.
"Some counselors worry the trend is widening the divide between haves and have-nots because early application programs often require those admitted to enroll. That proviso, known as “early decision,” tends to help the affluent.
Many students need to compare financial aid offers and weigh whether to take out loans.
...
"Still, highly selective colleges and universities often fill a third to half of their first-year classes through early rounds — which makes the regular round even more competitive. To address equity concerns, schools typically pledge to give students in need the same financial aid they would have received if they had been admitted in the regular cycle."

"Cadavers are irreplaceable in both the training of new medical students and medical research. Companies that make medical products also rely heavily on human tissue. Many medical schools operate their own donation programs, which provide the majority of cadavers needed for their education and research. However, many other bodies are obtained from body brokers. These body brokers, also known as non-transplant tissue banks, serve as middlemen between the recently deceased and the market for cadavers. They solicit donations from patients or their families, dismember or otherwise process the bodies as required, and sell what remains to the highest bidders. Each part has a price: a foot may sell for $250, a head might fetch $1,000. For these businesses, bodies are raw materials to be harvested and sold to other institutions for further use."